Concept: Fundamentals of Nursing 1

Lecturer: Sir JV Villanueva

Nursing – caring profession

Essence of Nursing – CARING
3 Blending factors of Nursing:
1. Art
2. Science
3. Spirit

4 Major Concepts in Nursing: (PEHN)

1. Person
2. Environment
3. Nursing
4. Health

4 Cornerstone of Nursing:
1. Health Promotion
2. Illness Prevention
3 Levels of Prevention:
a. Primary – healthy patient; (-) disease
Main goal: Health teaching or health education
b. Secondary – unhealthy patient; (+) disease
Main goal: screening, early detection, prompt treatment
c. Tertiary – rehabilitation and recovery
3. Curative stage
4. Care for death and dying

Act 2808 – First true nursing law

- nursing students must take Nursing Licensure Examination
- signed on March 1919

1920 – first Nursing Licensure Examination

3 Important Personality (Act 2808)

1. Dr. Juan Cabarrus
2. Belen dela Cruz
3. Anastacio Giron Tupaz – founder of PNA

Filipino Nursing Association – old name of PNA

Nursing Process – cornerstone or foundation of Nursing Profession

- “dynamic” (ever changing)
- systematic and rational method of planning and providing individualized nursing care

Lydia Hall – one who proposed Nursing process

Characteristics of Nursing Process (SUCU)
1. Sequence (may order)
2. Use of critical nursing skills
3. Client – centered
4. Universal (applicable to all clientele) – individual, family, and community

Tasks of Nurses: GOSH

- Goal – oriented
- Organized
- Systematized
- Humanistic Care (Human)

ADOPIE
1. Assessment – systematic gathering of data
- Main purpose: “gather data” / database – information about the client
- systematic (COVR) of data
a. collection of data
b. organization of data
c. validation of data
d. recording of data

Methods of data collection:

1. interview – face to face, purposeful conversation
2 Types: time is limited, questionnaire, closed ended question
a. Formal – directive, structured, emergency department
b. Informal – indirective, unstructured, free flowing, build rapport, open – ended
question
2. Observation – “senses”
3. Physical Assessment
- systematic
- cephalocaudal approach (head to toe)
- IPPA
4. Records Review
5. Diagnostic findings and Procedures

Types of Data
1. Subjective – sabi ng patient
- systematic
- covert data

2. Objective – observe as nurse

- overt data
- signs

Sources of Data:
1. Primary – directly in patient na gather ang data
2. Secondary
- a, patient chart
- b. significant others
- c. other health teams

IPPA
1. Inspection – sense of sight; color, shape, size and symmetrical
2. Palpation – sense of touch
2 Types of Palpation
a. Light – dominant hand, 3 middle fingers, e.g. breast self examination
b. deep/ bimanual – dominant (palpate) and non-dominant hand (hold or support)

Reminders in Palpation:
1. Light palpation first – deep palpation; rationale: pwede kang magkaroon ng
dull senses
2. Deep palpation – use of cautious or skillful hand
3. Wilhm’s Tumor – dissemination of cancer cells
3. Percusion – striking or tapping of body surface to produce sound
2 Types:
a. Direct – use of dominant hand
b. Indirect – use of pleximeter (non dominant hand) and flexor (dominant hand)

5 Percussion sounds:
1. dull sound – dense tissue area; e.g. heart, liver, spleen
2. flat sound – very dense tissue area; e.g. muscles and bones
3. resonance – normal lungs
4. hyperresonance – abnormal lungs; e.g. emphysematous lungs
5. tympanic – air-filled stomach; e.g. empty stomach
4. Auscultation
a. direct – use of unaided ear; e.g. bronchial asthma in acute exacerbation; no
need to use stethoscope; (+) respiratory wheezing without using stethoscope
b. indirect – use of stethoscope

General Guidelines in Physical Assessment:

1. Psychological preparation – explains the procedure
2. Physical preparation – empty the bladder (in Paracentesis)
3. Environmental preparation – provide warm, quiet, well – ventilated room; provide
privacy
4. Preparation of equipments/ materials

Abdominal Assessment IAPePa